AAPD Pediatric Oral Health Research & Policy Center

Re-emergenceA Report on Pediatric Dental Practice Re-entry into Practice During the COVID-19 Pandemic

2 | Re-emergence

INTRODUCTION AND BACKGROUND. Developing out of Wuhan, China, and setting an unprecedented course across the globe, the SARS-CoV-2 outbreak hit the United States with the unpredictability of a novel virus1,2. Social and physical distancing/“stay-at-home” measures were determined to be the premier meth-od of prevention in communities when the pandemic was largely uncontrolled in the early spring of 2020, necessitating the closures of schools, businesses, places of worship, parks and more2,3. Dental practices were not spared of these effects; they were mandated to triage and remain closed to routine services until infor-mation about virus transmission in the dental practice was better understood 4,5,6.

On March 16, the American Dental Association (ADA) recommended that practices postpone all but urgent and emergency appointments for three weeks5. By April 1, the recommendations were extended through the entire month5. Depending upon location and state/local regulations, practices re-opened in late April – early May 20207. During re-opening, the pediatric dental community was compelled to act creatively, com-passionately and wisely. Practices featured universal precautions with enhanced infection control based on the emerging evidence and recommendations8 and new approaches to seeing patients such as teledentist-ry9,10,11. The American Academy of Pediatric Dentistry (AAPD) recognized the need for guidance to members returning to practice. On April 28, 2020, the AAPD issued “Re-emergence Pediatric Dentistry Practice Check-list: A guide for re-entry into practice for pediatric dentists during the COVID-19 pandemic”12 to serve as a roadmap to providing a safe environment for patients, dental staff and dentists during a time when knowl-edge of the virus was evolving, and the risk of transmission in the dental setting was still uncertain.

AAPD Pediatric Oral Health Research & Policy Center

AAPD SURVEY. In keeping with the AAPD philosophy of research and assessment, and to augment existing re-emergence data with the pediatric dentist experience, the AAPD Policy Center developed a survey on key issues affecting pediatric dental practices as they began opening their doors. Between June 2 and July 1, the AAPD State Public Policy Advocate (PPA) Network was recruited to partic-ipate. The AAPD received 45 responses, representing 90 percent of U.S. states. The results yielded valuable tips on the effective strate-gies in resuming care during the pandemic. Other results revealed that the mental well-being of dentists was considerably impacted by the pandemic at the time the survey was administered.

Re-emergence | 3

Open for routine services1%

Closed to all patients16%

Open to patients needing emergency care only

83%

KEY HIGHLIGHTS. As of April 1, 83 percent of pediatric practices were seeing patients for emergencies only, 16 percent were closed to all patients, and one percent were open for routine care13. According to the AAPD survey to state PPAs, as of July 1, 80 percent of respondents reported practices allowed full operation.

BENEFICIAL APPROACHES TO PRACTICE DURING THE COVID-19 PANDEMIC. Two approaches were reported as most beneficial to reopening dental practice:

• Making recommended procedure and physical modifications was most beneficial to 51 percent of respondents.

• Motivating and caring for staff was most beneficial to 38 percent of respondents.

State Access to Dental Services During the COVID-19 Pandemic (04/01/2020)

State Access to Dental Services During the COVID-19 Pandemic (07/01/2020)

State does not allow full range of dental services20%

State allows full range of dental services

80%

Source: ADA HPI COVID-19 Economic Impact on Dental Practices Weekly Report

Source: AAPD Re-entry to Practice Survey

0

6

12

18

24

Making recommended procedure and

physical modi�cations

Motivating and caring for sta�

Resuming our usual practice

e�orts and answering

questions as needed

Ensuring that families know

your safety e�orts

Promoting reopening on

website and/or calls to families

All e�orts have been

equally e�ective

Don’t know

Source: AAPD Re-entry to Practice Survey

Reporting the top one or two most valuable practices during re-entry into practice during COVID-19 Pandemic

4 | Re-emergence

Only personnel are being monitored 2%

Only patients are being monitored7%

Both patients and personnel are being monitored22%

Don’t know if there is monitoring29%

No monitoring40%

MONITORING TRANSMISSION OF COVID-19 IN DENTAL OFFICES. As of July 1, nine percent of state PPAs reported that they had heard of a transmission of COVID-19 within a dental practice. Monitoring of transmis-sion in dental practices varied across states.

Is there any monitoring of patient or dental personnel in your state being conducted?

Which steps have been most effective getting practices going again?• Use of 6” buttons with image of staff member so kids could see who was behind the PPE and reopening

videos for kids.

• Being up front with families about the physical changes and PPE has helped to grasp the gravity of COVID-19.

• Communication of safety efforts.

• Ensuring supply chain PPE/supplies; working with government relations lobby firm, state health officer, dental board.

• Posting in social media.

• Reading CDC guidelines, state health department guidelines, and the referenced source material.

• Return to work guidelines, team meetings.

• Teledentistry has been helpful. Patient needs are addressed via a telephone consultation rather than in person.

• Use of Facebook by practices.

• Videos and examples of what to expect; what we look like in the PPE; the AAPD checklilst and ADA toolkit.

Source: AAPD Re-entry to Practice Survey

Re-emergence | 5

AAPD Pediatric Oral Health Research & Policy Center

PERSONAL PROTECTIVE EQUIPMENT (PPE). PPE emerged as a major issue for the majority of practices. 96 percent of states reported PPE shortage issues, spe-cifically that they did not have enough N95/respirator masks to wear one per patient.

RECOGNIZING THE SIGNIFICANT NEED FOR PPE, THE AAPD IN PARTNERSHIP WITH THE AAPD FOUNDATION COMMITTED TO PROCURING PPE ON BEHALF OF MEMBERS.

No91%

Yes9%

Do you have enough N95/respirator masks to wear one per patient?

“The AAPD Foundation allocated up to $1.6 million to offer all AAPD members one 50 count box supply of KN95 masks at no charge, in a joint collaboration between

the American Academy of Pediatric Dentistry and the AAPD Foundation.  More than 5,200 orders were received between August and September.”

Source: AAPD Re-entry to Practice Survey

PATIENT VOLUME BEFORE AND AFTER OFFICE CLOSURES

Comparison of latest total patient volume compared to pre-COVID volume

DATE 25-50% of 51-75% of 76% or more of pre-pandemic volume pre-pandemic volume pre-pandemic volume

9/21 9/21 4% 17% 77%4% 17% 77%

7/1 27% 29% 33% 7/1 27% 29% 33%

Source: AAPD Re-entry to Practice Survey, ADA HPI COVID-19 Economic Impact on Dental Practices Weekly Report

FINDINGS OF MENTAL WELLBEING. THE AAPD FOUND THAT 78 PERCENT OF PPAS WERE AWARE OF COLLEAGUES IN PEDIATRIC DENTISTRY WHO EXPERIENCED SIGNIFICANT STRESS DUE TO THE PANDEMIC AND 36 PERCENT REPORTED THEY HAD GONE THROUGH SIGNIFICANT WORRY AND STRESS BECAUSE OF THE EFFECT ON THEMSELVES AND THEIR PRACTICE.

• On Aug. 26, the AAPD convened a town hall to address mental health in the member community featuring Pedo Teeth Talk host, Dr. Joel Berg; AAPD President, Dr. Jessica Lee; and guest, Dr. Sheela Raja, Licensed Clinical Psychologist, Author and Associate Professor and Director of Clinical Behavioral Sciences at the University of Illinois at Chicago College of Dentistry.

• Based on the positive feedback, the AAPD has committed to continued mental health support of its members through future programming and work within the Safety Committee.

6 | Re-emergence

MOVING FORWARD FOR PEDIATRIC DENTISTRY. An evaluation of how the COVID-19 crisis has affected the pediatric dental community has shown it was critical to be open to care for their patients in need. Oral health care is a medical necessity and has been found to be safe for patients during the COVID-19 pandemic14,15.

PREPARING FOR THE NEXT DISASTER. Hurricanes, floods and forest fires converged in the U.S. during the Pandemic of 202016, making clear that future events will require a process-oriented disaster plan to help guide members in mitigating a range of emergency situations as they come up. Members can expect to hear more about dental preparedness planning in the months to come.

ONGOING MEMBER OUTREACH. A second member survey will be distributed once a vaccine is available, or if there is another major status change during the COVID-19 pandemic.

INTERIM RECOMMENDATIONS. To stay up-to-date on the latest COVID-19 information for dentistry, members can follow the regularly updated Re-emergence Pediatric Dentistry Practice Checklist. The AAPD also recommends the following:

1. Acting in accordance with the advice of state and U.S. professional organizations, and

2. Tracking general dental practices through the ADA HPI weekly survey on the COVID-19 economic impact on dental practice.

The AAPD is encouraged by the return to routine care by many of our members, the collaboration of members during the pandemic, and the progress that has been made by state Public Policy Advocates

as we faced a very difficult situation. Everyone, keep safe and well, until next time!

Re-emergence | 7

REFERENCES1. World Health Organization. Origins of SARS-CoV-2. https://www.who.int/publications/i/item/origin-of-sars-cov-2. Published March 2020. Accessed October 2, 2020.

2. Nicola M, Alsafi Z, Sohrabi C, et al. The socio-economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg. 2020;78:185-193. doi:10.1016/j.ijsu.2020.04.018

3. Centers for Disease Control and Prevention. Implementation of Mitigation Strategies for Communities with Local COVID-19 Transmission. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/community-mitigation.html. Updated May 27, 2020. Accessed October 2, 2020.

4. Nasseh K, Vujicic M. American Dental Association. Modeling the impact of COVID-19 on U.S. dental spending: Health Policy Institute Research Brief. https://www.ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIBrief_0620_1.pdf?la=en. Published April 2020. Accessed October 2, 2020.

5. American Dental Association. ADA Calls Upon Dentists to Postpone Elective Procedures. ADA News. March 16, 2020. Available at: https://www.ada.org/en/press-room/news-releases/2020-archives/march/ada-calls-upon-dentists-to-postpone-elective-procedures. Accessed October 2, 2020.

6. American Dental Association. ADA Urges Dentists to Heed April 30 Interim Postponement Recommendation, Maintain Focus on Urgent and Emergen-cy Dental Care Only. ADA News. April 1, 2020. Available at: https://www.ada.org/en/press-room/news-releases/2020-archives/april/summary-of-ada-guidance-during-the-covid-19-crisis. Accessed October 2, 2020.

7. American Dental Association. COVID-19 State Mandates and Recommendations. Available at: https://success.ada.org/en/practice-management/pa-tients/covid-19-state-mandates-and-recommendations?utm_source=adaorg&utm_medium=adanews&utm_content=stateaction&utm_campaign=-covid-19. Updated August 7, 2020. Accessed October 2, 2020.

8. Brian Z, Weintraub JA. Oral Health and COVID-19: Increasing the Need for Prevention and Access. Prev Chronic Dis 2020;17. Prev Chronic Dis 2020;17:200266. DOI: http://dx.doi.org/10.5888/pcd17.200266

9. California Dental Association. Teledentistry beyond COVID-19: Applications for private practice. CDA News. June 25, 2020. Available at: https://www.cda.org/Home/News-and-Events/Newsroom/Article-Details/teledentistry-beyond-covid-19-applications-for-private-practice. Accessed October 2, 2020.

10. Manatt, Phelps & Phillips, LLP. Executive Summary: Tracking Telehealth Changes State-by-State in Response to COVID-19. https://www.manatt.com/insights/newsletters/covid-19-update/executive-summary-tracking-telehealth-changes-stat. Updated September 18, 2020. Accessed October 2, 2020.

11. Centers for Disease Control and Prevention . Guidance for Dental Settings: Interim Infection Prevention and Control Guidance for Dental Settings During the Coronavirus Disease 2019 (COVID-19) Pandemic. Available at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/dental-settings.html. Up-dated August 28, 2020. Accessed October 2, 2020.

12. American Academy of Pediatric Dentistry. Re-emergence Pediatric Dentistry Practice Checklist: A guide for re-entry into practice for pediatric dentists during the COVID-19 pandemic. Available at: https://www.aapd.org/link/8a3864bdb3684db19145486aca0d4bcc.aspx. Accessed October 5, 2020.

13. American Dental Association. COVID-19 Economic Impact - Survey Results. https://www.ada.org/en/science-research/health-policy-institute/covid-19-dentists-economic-impact/survey-results. Accessed October 2, 2020.

14. American Academy of Pediatric Dentistry. Policy on medically necessary care. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2019:22-27. https://www.aapd.org/research/oral-health-policies--recommendations/policy-on-medically-neces-sary-care/.

15. Chow K, Epstein JB, Mathias R. Dental procedure aerosols and COVID-19 [published online ahead of print August 10, 2020]. Lancet Infect Dis. https://doi.org/10.1016/S1473-3099(20)30636-8.

16. Salas RN, Shultz JM, Solomon CG. The Climate Crisis and COVID-19 – A Major Threat to the Pandemic Response. N Engl J Med 2020; 383:e70. DOI: 10.1056/NEJMp2022011. Available at: https://www.nejm.org/doi/full/10.1056/NEJMp2022011. Accessed October 5, 2020.:

AAPD Pediatric Oral Health Research & Policy Center

Re-emergenceA Report on Pediatric Dental Practice Re-entry into Practice During the COVID-19 Pandemic

AAPD Pediatric Oral Health Research & Policy Center Publications

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May 2017Pediatric Dentist Toolkit for Seeing Patients with Medicaid

May 2016Competition or Collaboration: Exploring the Relationship between Corporate Dentistry and Dental Training Programs

February 2015Unique Considerations for Medicaid Audits of Pediatric Dental Practices

https://www.aapd.org/research/policy-center/technical-briefs/

AAPD Pediatric Oral Health Research & Policy Center